ETAP FINAL

A 12 year old girl presented to the clinic with history of lower abdominal pain after games of tennis, The pain affets both inguinal regions and is relieved by rest, worsened if she has played tennis after meals.

ETAP is commonly known as stitches to sportspersons. It is particularly common in exercises that include repetitive truncal movement, for example, running and horse riding. Almost 2/3 rds of regular runners are known to report this condition.City marathon and half-marathon events have noted almost 1 in 5 athlete to suffer from this with a spectrum of severity.

 ETAP commonly affects lateral borders of rectus abdominis ,costochondral junctions and shoulder tip. Sportspeople have subjectively described it as sharp,stabbing,cramping,aching,pulling or stitching pain. It has been reported to be worse after meals or ingestion of hypertonc fluids. It usually affects adolescents and young people 15-30 years of age.There is no diference between the sexes or any particular body types. The incidence might be less in well prepared sportspersons although cannot be completely eliminated.

No single mechanism is clear as a cause of ETAP. Possible theories include-

Diaphragmatic ischemia

Viscero-diaphragmatic ligantous stress

Gastrointestinal or mesenteric ischemia

External abdominal muscular cramp

Celiac artery compression by median arcuate ligament causing ischemic pain

Spinal nerve irritation

Parietal peritoneal irritation also known as exertional peritonitis

Strategies for managing the pain are largely anecdotal, especially given that its etiology remains to be elucidated. Commonly purported avoidance strategies include avoiing food and drinks for at least 2 hours prior to exercise, amending posture, especially in the thoracic region; and fortifying the abdominal organs by wearing an abdominal broad belt. Techniques for gaining palliation from the pain during an episode are equivocal.

Running, swimming, cycling, aerobics, basketball, and horse riding are the most common sporting activities associated with ETAP and STP.ETAP was respectively 10.5 and 9 times more common in running and horse riding than cycling. (1)

Age, gender, body mass index (BMI), training status, and sporting activity on the experience of ETAP and shoulder tip pain were assessed.With increasing age, ETAP and STP decreased.in prevalence and severity.Gender,BMI,and training status had n correlation with ETAP.Higher BMI persons complained more of STP. However, frequency of training tended to reduce ETAP incidents.Left sided ETAP was more common among younger sportspersons.STP was 13 times more common than cycling.

Isolated case reports suggest Median Arcuate Ligament Syndrome as a possible cause of ETAP, although it has been implicated as a cause of gastroparesis and post prandiel abdominal pain.A case is presented of a 18 year old hockey player with ETAP, failing all preventive measures for about 1 year and finally investigated for this condition also known as Coeliac Artery Compression Syndrome.Epigastric bruits increasing with expiration are reported in >2/3^rd of cases and may be the only clinical sign. Diagnosis is usually by MRA showing a "hook" deformity.Doppler duplex ultrasound can confirm the diagnosis.Surgical treatment is usually laparoscopic.(2,3)

There is a school of thought which believes ETAP is a result of diaphragmatic ischemia and /or spasm. High prevalence among horseback riders (an activity that doesn't really require heavy breathing), the pain sometimes being low in the abdomen, and the lack of change in spirometry (a measure of diaphragmatic strength) during a bout of ETAP points an etiology different from diaphragmatic pathophysiology.

Abdominal ligament stress is a theory put forward to explain some cases of ETAP.The gastrophrenic, lienophrenic, and coronary ligaments connect the diaphragm to the abdominal viscera.Mechanical stress on these ligaments, if not gradually built up, may be the cause of some cases of ETAP. This can explain occurrence of ETAP during horseback riding ( constant low-grade jolting), exercise after meals (additional weight needed to be supported by the ligaments), and the subjective benefit when wearing a supportive belt (eases some strain off of the ligaments). Evidence against a ligamental source includes the localized and sharp nature of the pain . Also the presence of ETAP in swimmers, who do not experience constant jolting thanks to support from the buoyancy of water goes against the theory of diaphragmatic ligamentous strain

Exertional peritonitis -a condition of parietal peritoneal irritation has been put forward to explain some cases of ETAP. It is a conjecture that during exercise, friction between jostling organs unused to the level of movement could cause the pain associated with ETAP.

Anecdotal physiotherapeutic management to treat ETAP , among sportspersons include

Slowing down, bending forward, and pushing his/her hand inward and upward on the area of pain.
• Tightening abdominal muscles, as if to resist a punch in the stomach.
• Breathing out through pursed lips.
• Changing footstrike-to-breathing cadence
• If the ETAP becomes unbearable, stopping exercising and walking slowly with arms raised over your head, to stretch out tightness, or lie on back with hips elevated.(4)